European Journal of Case Reports in Internal Medicine <p><strong>The&nbsp;<span class="HPblu">European Journal of Case Reports in Internal Medicine</span>&nbsp;</strong>is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from&nbsp;<a href="">33 European countries</a>.&nbsp;<br><br>The journal’s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field.&nbsp;<strong><br><span class="HPblu">EJCRIM&nbsp;</span></strong>welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight, contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors).&nbsp;<strong><br></strong>The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.<br><br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> SMC media s.r.l. - Via Giovenale 7, Milan - Italy en-US European Journal of Case Reports in Internal Medicine 2284-2594 <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href=""></a></p> The Clinical Significance of a ‘Crazy-Paving’ Pattern on Chest Radiology <p>A crazy-paving pattern is a non-specific radiological sign which is characterized by the presence of diffuse ground‐glass attenuation associated with interlobular septal thickening and intralobular lines. It was initially described as a pathognomonic sign of pulmonary alveolar proteinosis. However, it can be also found in many other diffuse acute and chronic lung diseases including diffuse alveolar haemorrhage (DAH), a rare and life-threatening clinical syndrome which can be caused by many conditions, the most frequent of these being capillaritis associated with systemic autoimmune diseases.<br> In this case report, we describe an 82-year-old female patient with acute respiratory failure and bilateral pulmonary infiltrates with the characteristic crazy-paving pattern. The final diagnosis was isolated DAH induced by microscopic polyangiitis. The patient was treated with IV high dose prednisolone and cyclophosphamide and was mechanically ventilated. Nevertheless, her clinical status progressively deteriorated and she died after 3 days from acute respiratory distress syndrome.</p> Ahmed Ehab Radu I Braga ##submission.copyrightStatement## 2018-12-14 2018-12-14 5 11 10.12890/2018_000978 Spontaneous Spinal Haemorrhage as a Complication of Oral Anticoagulant Therapy: A Case Report and Literature Review <p>Spinal cord haematoma, or haematomyelia, is a rare condition caused by several unusual disease processes. Traumatic events, such as spinal cord injury and surgery or procedures involving the spinal cord, are the most important causes of spinal cord haematoma. Rarely, it is associated with anticoagulation therapy. Irrespective of cause, spinal cord haematoma is considered a neurosurgical emergency and must be treated promptly in order to prevent neurological sequelae. The authors describe the case of a 69-year-old patient taking warfarin in the therapeutic range for a mechanic mitral valve, who developed chest pain with cervical and dorsal radiation, and experienced sudden paraparesis of the limbs. A CT of the spine confirmed haematomyelia. A high index of suspicion, prompt recognition and immediate intervention are essential to prevent major morbidity and mortality from intraspinal haemorrhage.</p> Ana Patricia Castanheira Gomes Eduardo Cernadas Juliana Sá Helena Brito Ricardo Costa ##submission.copyrightStatement## 2018-12-12 2018-12-12 5 11 10.12890/2018_000887 A Reflection on the Use of Enoxaparin Based on Three Case Reports <p>Enoxaparin is indicated for the treatment or prevention of many clinical disorders including deep vein thromboembolism, atrial fibrillation and mechanical valve thrombosis. It is one of the most commonly prescribed drugs in hospitals. However, haemorrhagic complications can occur, particularly in the elderly, patients with renal function impairment and patients with a very high or very low body weight. The authors describe the cases of three patients who had one or more risk factors for haemorrhagic complications, such as abdominal haematomas. The clinical presentation was similar in all three cases, with sudden-onset abdominal pain, an altered state of consciousness and hypotension. In all cases, investigation showed acute anaemia and large abdominal haematomas on imaging studies. A conservative approach was taken in the three patients, with suspension and reversal of anticoagulation, fluid resuscitation and red blood cell transfusion. Haemodynamic stability was achieved in two of the patients, but the third patient died.<br> The authors consider it is important to present these case reports because of the widespread use of enoxaparin, and the need for rigorous dose adjustment for renal function variations and body weight. We hope this article raises awareness of haemorrhagic complications in high-risk groups and propose protocols are introduced for dose adjustment and monitoring the efficacy of enoxaparin.</p> Rui Costa Inês Ferreira Inês Egídio De Sousa Mariana Martins Carolina Gouveia Patrícia Vicente Ana Pedroso ##submission.copyrightStatement## 2018-12-10 2018-12-10 5 11 10.12890/2018_001000 Mauriac Syndrome: A Rare Complication of Type 1 Diabetes Mellitus <p>Mauriac syndrome, first described in 1930, is typically diagnosed in young patients with poorly controlled type 1 diabetes mellitus and growth retardation, delayed puberty, Cushingoid features, hypercholesterolaemia and hepatomegaly. However, the sole presenting feature of Mauriac syndrome can be hepatic glycogenosis in both adults and children. The mainstay of treatment for hepatic glycogenosis is strict control of glucose levels, with an excellent prognosis with improved glycaemic control. The authors present the case of a 22-year-old female patient with type 1 diabetes mellitus and a history of poor glycaemic control who was admitted with diabetic ketoacidosis (DKA). She complained of episodes of right upper quadrant abdominal pain associated with nausea and vomiting for the last 2 months with worsening in the last 48 hours. Physical examination was remarkable for short stature and tenderness over the hepatic area with a mildly enlarged liver. The patient had elevated liver enzymes and persistent hyperlactacidaemia despite DKA resolution. Liver imaging suggested diffuse fat infiltration. The clinical suspicion of hepatic glycogenosis was confirmed by liver biopsy. After glycaemic control was improved, liver enzymes normalized and the episodes of abdominal pain, nausea and vomiting subsided.</p> Maria João Rodrigues Ferreira Pinto Nuno Melo Luís Flores Francisco Cunha ##submission.copyrightStatement## 2018-12-06 2018-12-06 5 11 10.12890/2018_000969 Non-Uremic Calciphylaxis: A Rare Diagnosis with Limited Therapeutic Strategies <p>Calciphylaxis is a rare condition characterized by the emergence of non-healing skin ulcers secondary to arterial calcification and thrombosis, typically diagnosed in patients with end-stage kidney disease (ESKD). When it develops in patients without ESKD, it is called non-uremic calciphylaxis (NUC). The latter is an even rarer diagnosis with an uncertain pathophysiology and a high mortality rate (52%), mainly due to sepsis (50%). Cutaneous biopsy is diagnostic. Therapeutic measures recommended for NUC are limited to wound debridement, analgesia, and control of infection and risk factors. Other therapeutic options exist but with a low level of evidence. We present the case of a 78-year-old woman with NUC in her lower limbs who died of sepsis. NUC is a therapeutic challenge lacking efficient strategies.</p> Felisbela Miguel Gomes Pedro La Feria Catarina Costa Rita Santos ##submission.copyrightStatement## 2018-12-04 2018-12-04 5 11 10.12890/2018_000986 Acute Non-Rheumatic Myopericarditis: A Rare Complication of Pharyngitis <p>Acute non-rheumatic streptococcal myopericarditis (ANRSM) is a rare complication of an upper airway infection by streptococcus group A in developed countries. Cardiac involvement in bacterial infections must be adequately treated because it can lead to long-term complications. This case report describes recurrent ANRSM in an 18-year-old man, which illustrates how difficult and challenging the diagnosis of this disease can be.</p> Rafael Silva Luís Puga Rogério Teixeira Ana Botelho Carolina Lourenço Lino Gonçalves ##submission.copyrightStatement## 2018-11-29 2018-11-29 5 11 10.12890/2018_000987 Fatal Septic Shock Associated with Herpes Simplex Virus Hepatitis: A Case Report <p>Herpes simplex viruses are endemic worldwide, with an estimated seroprevalence of approximately 70% in developed countries. However, it is less well known that they are one of the viral causes of fulminant hepatitis (&lt;2%) and constitute &lt;1% of all causes of acute liver failure. We describe the case of an 89-year-old man who developed sepsis caused by a urinary tract infection due to drug-sensitive <em>Escherichia coli</em>. After empirical treatment with piperacillin-tazobactam was initiated, the patient’s condition worsened with shock, acute liver and renal failure, encephalopathy and persistent fever, that led to admission to the intensive care unit. The emergence of an acute abdomen prompted exploratory laparotomy but the patient died soon after surgery from abdominal haemorrhage. Immunohistochemical analysis of a liver biopsy specimen identified herpes simplex virus (HSV) hepatitis. The authors emphasize the need for better understanding of this rare condition in order to more precisely identify patients at risk who need more aggressive evaluation and empirical treatment, especially patients presenting with marked hepatic cytolysis with a rapidly worsening clinical evolution.</p> Valentine Inthasot Adonis Goushchi Silvia Lazzaroni Alberto Papaleo Maria Gomez Galdon Didier Chochrad ##submission.copyrightStatement## 2018-11-27 2018-11-27 5 11 10.12890/2018_000982 Remitting Seronegative Symmetrical Synovitis with Pitting Oedema as the First Manifestation of an Adenocarcinoma of the Caecum <p>Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) is a rare syndrome that affects the elderly. Although the aetiology is not fully understood, it has been related to multiple diseases including cancer. We present the case of an 80-year-old man with a full spectrum of signs and symptoms compatible with RS3PE: sudden onset of bilateral polyarthralgia of the metacarpophalangeal and proximal interphalangeal joints, oedema of the dorsum of the hands, increased inflammatory markers and seronegative rheumatoid factor. After a 5-day course of corticotherapy, the patient became asymptomatic although maintaining a mild anaemia. During a search for the underlying cause of the RS3PE, an early stage adenocarcinoma of the caecum was diagnosed and surgically removed. No further treatment was performed and after 3 years of follow-up the patient remains without evidence of either paraneoplastic RS3PE or cancer.</p> Edgar Pratas João Carvalho Isabel Domingues João Fonseca Teresa Carvalho Gabriela Sousa Manuel Teixeira Veríssimo ##submission.copyrightStatement## 2018-11-22 2018-11-22 5 11 10.12890/2018_000976 Mycoplasma pneumoniae-associated Mucositis: A Recently Described Entity <p><em>Mycoplasma pneumoniae</em> (MP) is a common cause of respiratory infections and can be associated with extrapulmonary complications. MP mucositis has recently been described as a distinct endemic clinical entity called <em>Mycoplasma pneumoniae</em>-induced rash and mucositis (MIRM). The authors present the case of a 46-year-old man with atypical pneumonia associated with exuberant mucositis, conjunctival hyperaemia and positive serological assays for MP IgM. The patient was treated with azithromycin and systemic corticosteroid therapy. Supportive care including pain management, intravenous hydration and mucosal care was also given. There was complete resolution of the pneumonia and mucositis. The presence of atypical pneumonia with mucosal involvement without cutaneous lesions and a favourable clinical evolution led to the diagnosis of MIRM.</p> Inês Zão Fani Ribeiro Valter Rocha Pedro Neto Carla Matias Gorete Jesus ##submission.copyrightStatement## 2018-11-20 2018-11-20 5 11 10.12890/2018_000977 The Hippocratic Splash <p>Although the current medical literature is limited, hydropneumothorax was described as far back as the 5th century BC. It is characterized by the presence of air and fluid in the pleural cavity and is an infrequent finding. Causes include trauma, iatrogenesis following thoracentesis, the presence of gas-forming organisms, tuberculosis and malignancy. Diagnosis is based on clinical and radiological features. We report a case of hydropneumothorax and present radiological images showing the distinctive features of this entity.</p> Geetha Girithari Inês Coelho dos Santos Eva Claro Serguey Belykh David Matias Orlando Santos ##submission.copyrightStatement## 2018-11-13 2018-11-13 5 11 10.12890/2018_000975